Information Collection

Physician Annual Burden for Completing the Electronic and Paper Clinical Template

IC 219423 under ICR 201512-0938-012 · OMB 0938-1318.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10564 Physician Annual Burden for Completing the Electronic and Paper Clinical Template	Form and Instruction
CMS-10564 Progress Note and Guidance CMS-10564. 091916 Clean version Revised HH Paper and ElectronicTemplate.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 485.638 42 CFR 424.22 (a)(1)(v)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10564	Progress Note and Guidance	CMS-10564. 091916 Clean version Revised HH Paper and ElectronicTemplate.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,926,420

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 20 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,926,420	2,926,420
Annual IC Time Burden (Hours)	1,220,317	1,220,317
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.